Health inspection·April 29, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview and review of manufacturer's instructions, the facility failed to ensure medication error rates were not five percent or greater when staff failed to prime two insulin pens for Resident #7. There was 32 medication administration opportunities with two errors, for a medication error rate of 6.25%. This affected one (Resident #7) of three residents reviewed for medication administration. The facility census was 93. Residents Affected - Few Findings include: Review of Resident #7's medical record revealed an admission date of 02/04/23. Diagnoses included type II diabetes mellitus, chronic congestive heart failure (CHF), hyperlipidemia, hypertension, atherosclerotic heart disease of native coronary artery, atrial fibrillation, hypothyroidism, anxiety disorder, major depressive disorder, low back pain, chronic kidney disease, and gastro-esophageal reflux disease (GERD). Review of a physician order dated 03/22/23 revealed humalog kwikpen subcutaneous solution pen-injector 100 unit/milliliter insulin lispro inject 15 units subcutaneously three times a day related to type II diabetes mellitus, with additional units ordered based on blood sugar levels. Further review of a physician order dated 07/14/23 revealed lantus solostar 100 unit/milliliter solution pen-injector inject 40 units subcutaneously two times a day related to type II diabetes mellitus. Observation on 04/29/24 at 9:54 A.M. revealed Licensed Practical Nurse (LPN) #14 used a lantus solostar pen injector to draw up 40 units of insulin for Resident #7. LPN #14 did not prime the insulin pen before use. Observation on 04/29/24 at 10:00 A.M. revealed LPN #14 used a humalog kwikpen pen injector to draw up 17 units of insulin for Resident #7. LPN #14 did not prime the insulin pen before use. The dose was scheduled 15 units of insulin and two additional units for coverage based on blood sugar levels. Interview on 04/29/24 at 10:25 A.M. with LPN #14 verified she did not prime the humalog kwikpen or lantus solostar insulin pen prior to administration to ensure Resident #7 received the appropriate dosages. LPN #14 stated she was unaware of how to prime the insulin pens. Review of the humalog kwikpen instructions, undated, revealed to prime the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and a zero is seen in the dose window. Hold the dose knob in and count to five slowly. You Page 1 of 4 366387 366387 04/29/2024 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should see insulin at the tip of the needle. If you do not see insulin repeat priming steps no more than four times. Review of the lantus solostar instruction guide, undated, revealed to always perform the safety test before each injection. This ensures that you get an accurate dose by ensuring the pen and needle work properly and removing any air bubbles. To complete the safety test, select a dose of two units. Take off the outer needle cap and keep it to replaced on the used needle after injection. Take off the inner needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before the insulin is seen. If no insulin comes out, the needle may be blocked. Change the needle and try again. You must perform safety tests before you use the pen until you see insulin coming out of the needle tip. If you do not see insulin coming out before taking your dose, you could get an underdose or no insulin at all. This could cause high blood sugar. This deficiency represents non-compliance investigated under Complaint Number OH00153387. 366387 Page 2 of 4 366387 04/29/2024 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and review of insulin pen manufacturer's instructions, the facility failed to ensure residents were free from significant medication errors when staff failed to prime two insulin pens for Resident #7. This affected one (Resident #7) of three residents reviewed for medication administration. The facility census was 93. Residents Affected - Few Findings include: Review of Resident #7's medical record revealed an admission date of 02/04/23. Diagnoses included type II diabetes mellitus, chronic congestive heart failure (CHF), hyperlipidemia, hypertension, atherosclerotic heart disease of native coronary artery, atrial fibrillation, hypothyroidism, anxiety disorder, major depressive disorder, low back pain, chronic kidney disease, and gastro-esophageal reflux disease (GERD). Review of a physician order dated 03/22/23 revealed humalog kwikpen subcutaneous solution pen-injector 100 unit/milliliter insulin lispro inject 15 units subcutaneously three times a day related to type II diabetes mellitus, with additional units ordered based on blood sugar levels. Further review of a physician order dated 07/14/23 revealed lantus solostar 100 unit/milliliter solution pen-injector inject 40 units subcutaneously two times a day related to type II diabetes mellitus. Observation on 04/29/24 at 9:54 A.M. revealed Licensed Practical Nurse (LPN) #14 used a lantus solostar pen injector to draw up 40 units of insulin for Resident #7. LPN #14 did not prime the insulin pen before use. Observation on 04/29/24 at 10:00 A.M. revealed LPN #14 used a humalog kwikpen pen injector to draw up 17 units of insulin for Resident #7. LPN #14 did not prime the insulin pen before use. The dose was scheduled 15 units of insulin and two additional units for coverage based on blood sugar levels. Interview on 04/29/24 at 10:25 A.M. with LPN #14 verified she did not prime the humalog kwikpen or lantus solostar insulin pen prior to administration to ensure Resident #7 received the appropriate dosages. LPN #14 stated she was unaware of how to prime the insulin pens. Review of the humalog kwikpen instructions, undated, revealed to prime the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and a zero is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin repeat priming steps no more than four times. Review of the lantus solostar instruction guide, undated, revealed to always perform the safety test before each injection. This ensures that you get an accurate dose by ensuring the pen and needle work properly and removing any air bubbles. To complete the safety test, select a dose of two units. Take off the outer needle cap and keep it to replaced on the used needle after injection. Take off the inner needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several 366387 Page 3 of 4 366387 04/29/2024 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0760 Level of Harm - Minimal harm or potential for actual harm times before the insulin is seen. If no insulin comes out, the needle may be blocked. Change the needle and try again. You must perform safety tests before you use the pen until you see insulin coming out of the needle tip. If you do not see insulin coming out before taking your dose, you could get an underdose or no insulin at all. This could cause high blood sugar. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00153387. 366387 Page 4 of 4